For elderly patients receiving home healthcare after a hospital stay, "social environmental factors"—particularly care provided by a family member or other informal caregiver—have a significant impact on the risk of repeated hospital admissions, reports a study in the October-December issue of Advances in Nursing Science.

"Understanding how social environmental factors contribute to home healthcare patients being rehospitalized would be assist in improving care for patients and in helping agencies deliver more cost-effective care while at the same time managing Medicare spending," according to the report by Hong Tao, RN, PhD, of University of Wisconsin Milwaukee and colleagues.

Social Environmental Factors Affect Functional Abilities…

The study looked at factors affecting the risk of repeated hospital admissions among 1,268 elderly patients receiving home healthcare. Using data from routine, Medicare-required assessments, the researchers focused on the importance of social environmental factors: such as whether the patient lived alone or with others, whether he or she had a primary informal caregiver, and the type and frequency of informal care provided.

Overall, nearly 21 percent of patients in the study were rehospitalized, most within the first 20 days of being discharged from the hospital to home healthcare. Rehospitalizations—defined as readmission to the hospital within 60 days after being released from the hospital to home care—are an important indicator of the quality of care.

The study found some significant associations between social environmental factors, and suggested some pathways by which these effects occur. Patients' functional ability—their ability to take care of themselves—was influenced by their living arrangements and by the type and frequency of informal care they received.

The greater the difference between the patients' clinical condition and functional status, the greater the risk of rehospitalization. Social environmental factors contributed to the risk of repeated hospital admission by altering the balance between the patient's need for and ability to provide self-care.

…With 'Self-Care Deficit' Leading to Repeat Hospitalizations

Changes in clinical condition placed increased demands on the patient's ability to care for himself or herself, while at the same time making it more difficult to provide self-care. Consistent with a central nursing theory, the resulting "self-care deficit" was linked to an increased risk of rehospitalization.

The amount of care and assistance received from informal caregivers had an important impact on self-care ability and rehospitalization risk. Other patient characteristics linked to self-care deficit included obesity and cognitive (intellectual) ability. Patients living alone were less likely to be rehospitalized—perhaps because those choosing to live alone were better able to functional independently and care for themselves.

Few previous studies have looked at how social environmental factors in general, and informal caregivers in particular, affect patient outcomes. Rehospitalization is considered a "major adverse event" in home care. "Rehospitalizations are costly and in many cases preventable," Dr Tao and colleagues explain. One recent study found that 20 percent of hospitalized Medicare beneficiaries are readmitted within 30 days, with costs accounting for one-sixth of the total Medicare budget.

Dr Tao and colleagues believe their study has implications for strategies to reduce unnecessary rehospitalizations and improve the quality of home healthcare. "[Our] findings may help home healthcare nurses to recognize those patients who are in need of certain services that may reduce hospitalization, such as those that lack the support of the patient's family or assistance from paid informal caregivers," they write. Patients with good social environmental support are "more likely to have a higher functional ability and thus remain in their homes, the first choice of most patients."

The study also reaffirms the important role of informal caregivers in maintaining home healthcare patients. The authors add, "Informal caregivers are part of the solution in preventing unnecessary hospitalizations and more attention needs to be given to how these caregivers are supported in their roles."

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